CERVICAL SPINE INSTABILITY IN RHEUMATOID ARTHRITIS IN THE ERA OF MODERN ANTIRHEUMATIC THERAPY: PREDICTORS OF PROGRESSION AND TIMING OF NEUROSURGICAL REFERRAL

Grzegorz  Słomkowski; Klaudia  Pachulska; Natalia Sara Kuśmierowska; Milena Polak; Dominika  Karolak; Tymoteusz  Białowąs; Kacper  Cholewiński; Konrad  Wiśniewski; Magdalena  Nowak; Daria Valipur Kolti

doi:10.31435/ijitss.3(51).2026.6545

Authors

Grzegorz Słomkowski Faculty of Medicine, Medical University of Warsaw, Żwirki I Wigury 61, 02-091 Warsaw, Poland https://orcid.org/0009-0003-3742-8377
Klaudia Pachulska Faculty of Medicine, Medical University of Warsaw, Żwirki I Wigury 61, 02-091 Warsaw, Poland https://orcid.org/0009-0003-5105-8798
Natalia Sara Kuśmierowska Faculty of Medicine, Medical University of Warsaw, Żwirki I Wigury 61, 02-091 Warsaw, Poland https://orcid.org/0009-0006-7572-0282
Milena Polak Faculty of Medicine, Medical University of Warsaw, Żwirki I Wigury 61, 02-091 Warsaw, Poland https://orcid.org/0009-0007-6148-5354
Dominika Karolak Faculty of Medicine, Medical University of Warsaw, Żwirki I Wigury 61, 02-091 Warsaw, Poland https://orcid.org/0009-0007-1131-9171
Tymoteusz Białowąs Faculty of Medicine, Medical University of Warsaw, Żwirki I Wigury 61, 02-091 Warsaw, Poland https://orcid.org/0009-0001-0889-2635
Kacper Cholewiński Faculty of Medicine, Medical University of Warsaw, Żwirki I Wigury 61, 02-091 Warsaw, Poland https://orcid.org/0009-0004-7185-5310
Konrad Wiśniewski Cardinal Stefan Wyszyński University in Warsaw, ul. Kazimierza Wóycickiego 1/3, 01-938 Warsaw, Poland https://orcid.org/0009-0007-1076-6471
Magdalena Nowak Cardinal Stefan Wyszyński University in Warsaw, ul. Kazimierza Wóycickiego 1/3, 01-938 Warsaw, Poland https://orcid.org/0009-0002-1010-3364
Daria Valipur Kolti University Clinical Centre, Medical University of Warsaw, Żwirki I Wigury 61, 02-091 Warsaw, Poland https://orcid.org/0009-0005-9900-4419

DOI:

https://doi.org/10.31435/ijitss.3(51).2026.6545

Keywords:

Rheumatoid Arthritis, Cervical Spine, Atlantoaxial Instability, Cervical Instability, Disease Progression, Neurosurgical Referral

Abstract

Background and Objectives. To synthesize contemporary clinical evidence on rheumatoid cervical spine instability, identify predictors of structural progression, and distinguish the threshold for neurosurgical referral from the threshold for operative intervention.

Materials and Methods. A focused narrative clinical review was based on a PubMed/MEDLINE search updated through August 2026. Original clinical studies addressing cervical involvement, imaging, longitudinal progression, predictors, neurological consequences, and surgical outcomes were prioritized. Forty clinical publications formed the principal evidence base, no meta-analysis or formal risk-of-bias grading was performed.

Results. Modern disease-modifying antirheumatic therapy appears to reduce some de novo cervical lesions, but established instability may continue to progress. Pre-existing cervical abnormalities, destructive peripheral disease, longer rheumatoid arthritis duration, seropositivity, glucocorticoid exposure, osteoporosis, and previous joint surgery are associated with cervical involvement or progression. Serial imaging is particularly important because mechanical deterioration may precede overt neurological compromise.

Conclusions. Assessment should integrate rheumatological phenotype, established structural disease, longitudinal mechanical progression, and neural consequences. Neurologically intact patients with documented structural progression represent a clinically important intermediate group in whom earlier spine or neurosurgical assessment may be considered without implying prophylactic surgery.

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